Peptic ulcer perforation
ICD-10 K27.1 ICD-11 DA61/ME24.3Z1

Treatment of Peptic Ulcer Perforation with Peritonitis in a Hemodynamically Stable Patient

When a patient with perforated peptic ulcer remains hemodynamically stable but presents with significant pneumoperitoneum, extraluminal contrast extravasation, or signs of peritonitis, the clinical picture requires prompt decision-making about operative intervention and antibiotic therapy.

Clinical Scenario

Hemodynamically stable patient with perforated peptic ulcer and one or more of the following: significant pneumoperitoneum, extraluminal contrast extravasation, or signs of peritonitis.

Approach

This scenario calls for operative treatment performed as soon as possible. A laparoscopic approach is preferred where skills and equipment allow, and broad-spectrum antibiotics form part of the management. The specific operative technique is guided by the perforation characteristics — but the full decision framework, including how size and location shape the surgical choice, is detailed in the complete protocol.

Instant Access to Structured Evidence-Based Regimens

References

  1. In patients with perforated peptic ulcer with significant pneumoperitoneum or extraluminal contrast extravasation or signs of peritonitis, we recommend operative treatment (Strong recommendation based on low-quality evidences, 1C).
  2. We recommend performing surgery as soon as possible, especially in patients with delayed presentation and patients older than 70 years old (strong recommendation based on moderate-quality evidences, 1B).
  3. In stable patients with perforated peptic ulcer, we suggest a laparoscopic approach. An open approach is recommended in the absence of appropriate laparoscopic skills and equipment (weak recommendation based on moderate-quality evidences, 2B).
  4. In patients with perforated peptic ulcer smaller than 2 cm, we suggest performing primary repair.
  5. We suggest a tailored approach based upon the location of the ulcer for the treatment of perforated peptic ulcer larger than 2 cm. In case of large gastric ulcers that raise the suspicion of malignancy, we suggest resection with contextual operative frozen pathologic examination whenever possible. In case of large duodenal ulcers, we suggest considering the need of resections or repair plus/minus pyloric exclusion/external bile drainage.
  6. In patients with perforated peptic ulcer, we recommend the administration of broad-spectrum antibiotics (strong recommendation based on low-quality evidences, 1C).
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